Cardiac Arrest Ethical Issues

By Dr Ananya Mandal, MD

There are several legal and ethical issues surrounding the management of cardiac arrest patients, particularly in the case of an emergency setting that lies outside of the hospital setting. The responsibilities of first responders and initial caregivers are relatively clear but the ethical issues surrounding resuscitation in general are less clear and vary depending on local culture and the law.

Volunteering help in a cardiac arrest setting

"Good Samaritan" laws are the laws put in place to alleviate hesitation on the part of bystanders to assist individuals in danger due to fear of being prosecuted for causing injury or wrongful death. The principles of good Samaritan laws are more commonly in operation in countries where the foundation of the legal system is English Common Law, such as Australia.

Australian law encourages volunteers to act as good Samaritans when a person is undergoing cardiac arrest but does not make it a legal obligation to assist a fellow human. A good Samaritan is defined as a person who acts without expecting financial or other reward in return of his or her assistance.

Once the person decides to assist, their standard of care is expected to be appropriate to their training (or lack of training). A good Samaritan is expected, however, to at least show reasonable care and not act recklessly

Healthcare professionals and doctors

Trained healthcare workers and doctors who have been asked to assist a patient with cardiac arrest outside of the hospital or when they are not on duty, have a Common Law obligation to do so in most countries. However, consent should be obtained from the injured or ill person or their guardian before any assistance is provided.

The patient or guardian retains the right of autonomy and self-determination. Treating the patient without this consent is technically an assault and the victim could claim damages even without proof of injury or negligence.

Some circumstances however do not require consent, such as if a patient is unable to give consent or if a doctor (or other healthcare professional) believes honestly and reasonably that emergency treatment is necessary to prevent the patient's life. Within a hospital or approved medical practice, staff may act without consent if they believe they are acting in the best interest of the patient.

DNAR or NFR may apply in cases where a patient in cardiac arrest is chronically ill or has a terminal illness. In these situations, healthcare professionals may have been specifically ordered not to intervene. The application of DNAR may be considered when resuscitation attempts seem futile or a patient has expressed a wish not to be resuscitated.

Presence of family member during resuscitation

Studies have provided evidence to suggest that the presence of a family member while a person is undergoing cardiac arrest has neither a negative or positive effect on patient outcome at the time of resuscitation, regardless of whether the person is a child or an adult. Currently, most recommendations suggest that family members of a person undergoing cardiac resuscitation should be given the option of being present.

Stopping resuscitation attempts

The presence of co-morbidity and how promptly a patient presents at hospital are important factors affecting the likelihood of successful resuscitation. Opinions and policy vary widely regarding whether or not resuscitation should be stopped.

One study looking at out-of-hospital cardiac arrest showed that among patients who had no shockable rhythm, no spontaneous restoration of circulation and an arrest that had not been witnessed by emergency services, the survival rate was only 0.5% when medical technicians tried to resuscitate individuals using defibrillation.

Ethics concerning organ and tissue donation

Clearly defined guidelines for organ and tissue procurement are available at hospitals and these vary between countries. If death occurs outside of a hospital however, permission for organ and tissue donations needs to be obtained from the person's relatives.

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